Ep. 42: Screening Illicit Drugs to Prevent Fentanyl Deaths

Welcome to the reboot of The Undark Podcast, which will deliver — once a month from September to May — a feature-length exploration of a single topic at the intersection of science and society. In this episode, join freelance journalist Zachary Siegel and podcast host Lydia Chain as they explore the harm reduction organizations taking the controversial step of testing illicit drugs with forensic lab equipment to reduce fentanyl overdoses.

Below is the full transcript of the podcast, lightly edited for clarity. You can also subscribe to The Undark Podcast at Apple Podcasts, TuneIn, or Spotify.

Greg Scott: I sort of have this vision in my head that there is a dam around the city of Chicago. There’s a huge reservoir of fentanyl all across North America. But for some reason, there are only a few holes in that dam that surrounds Chicago and fentanyl’s getting in, but it’s not getting in at any substantial level.

Zachary Siegel: That’s Greg Scott, a professor of sociology at DePaul University who works closely with the Chicago Recovery Alliance, a nonprofit that provides overdose prevention, sterile injection equipment, and other health services across the city. The illicit drug supply in Chicago and across America is changing, and it’s making him worry about the people he serves. Markets that used to be dominated by heroin are now seeing a new and potent drug creep in: a group of synthetically produced opioids called fentanyl and fentanyl analogs.

Greg Scott: At some point, somebody is going to take a pickaxe to one of those holes, and we’re going to see, essentially, flooding. And when you have, at the population level, a supply line going from 1 percent concentration to 5 percent concentration, you are then going to encounter a situation of mass casualty, that is my fear.

Lydia Chain: This is The Undark Podcast. I’m Lydia Chain. Between 1999 and 2017, the opioid epidemic killed nearly 400,000 Americans. Over the years, the drugs behind the majority of overdose deaths have shifted, first prescription painkillers, then heroin, and starting in 2013, a wave of synthetic opioids, primarily fentanyl and its analogs.

Pharmaceutical fentanyl is used for pain management in cancer treatment and end of life care. But it and chemical variations of it are also produced in illicit labs. Both sources enter the illicit drug market, but it’s the clandestinely produced drugs that are often sold mixed in with, or even masquerading as other, less powerful drugs. It’s been a threat decades in the making, slowly growing beyond the East Coast to reach middle America. But as overdose deaths climb and the market changes to include more of these dangerous analogs, experts fear that the epidemic will worsen.

Some harm reduction organizations are reacting by helping drug users know what they’re taking. But like many other efforts to make it safer to use illegal substances, it’s a complex and controversial topic. Zachary Siegel has the story.

Lydia Karch: So this sample came from a van shift that I work with one of the CRA outreach staff. And this is a participant who knows us pretty well. There’s a long relationship and a history with CRA and she was one of the first people to start using drug checking services and so I actually felt like she kind of tested with me with a couple things and now she pretty regularly brings multiple samples to be tested.

Zachary Siegel: I’m with Lydia Karch at CRA’s warehouse, an old carwash sandwiched between the East Garfield Park and the Lawndale neighborhoods on Chicago’s West Side. Karch is a field worker of the CDC Foundation, which is an independent nonprofit that Congress created to support the Centers for Disease Control and Prevention. The warehouse is bustling during drop-in hours. On Wednesdays, volunteers pack hundreds of kits stuffed with syringes, gauze, and tiny blue bottles of sterile water, among other items, that they give away for free and ship around the country to other harm reduction organizations. Box upon box of these materials are stacked from floor to ceiling. And it’s here where people bring in samples of illicit drugs they’re planning to consume, and Karch gets to work figuring out what those little baggies of white powder actually contain.

Lydia Karch: It’s white. It’s white powder. And so I put it on our infrared spectrometer. It runs scans and it measures the absorption, and then it will pop up a spectra on the laptop connected to the machine for me or another technician to analyze.

Zachary Siegel: Karch is specifically looking for illicit fentanyl. The West Side carwash is now a makeshift forensic lab of sorts. In front of us are two machines: one that uses infrared spectroscopy and the other, high pressure mass spectrometry. These are pieces of expensive forensic laboratory equipment that are able to provide comprehensive information about the chemical composition of a mystery substance. They’re typically used by law enforcement agencies to aid prosecutions, medical examiners to conduct death investigations, or in war zones to detect dangerous chemicals.

Lydia Karch: And so the advantage of this is it gives us a sense of everything that is in the samples so we start with this one because you can see the cuts and then anything that is below 5 percent, the machine is likely to miss. And so after that I will move on to the other two tests that capture things at a lower concentration.

Zachary Siegel: Karch also uses a much cheaper, low-tech method: fentanyl test strips. These basically look like pregnancy tests and are available to the general population. But while they are very sensitive, they just give a simple yes or no. Karch’s tests can give a more granular analysis of the sample, and that’s important because the more information one has about what they’re using, the more they can think through the safest ways to use it.

Since 2015, opioid-related deaths have increased by nearly 500 percent across Chicago, according to a Chicago Tribune review of medical examiner records. Overdoses in Chicago also look much different than in, say, rural Ohio or Appalachia, where stories about overdoses often take place. A brief issued by the Chicago Urban League noted that opioid deaths more than doubled among African Americans in Illinois from 2013 to 2016. A lot of these deaths took place in Chicago, a super segregated city. Neighborhoods where crack and heroin are bought and sold have experienced decades of red-lining and divestment — the structural forces of racism.

While heroin use is not new to Chicago, overdose deaths are trending upward, especially among people of color, largely due to these powerful fentanyls — potent opioids that require no land or sunlight to produce, just a lab and the right chemical precursors. This new family of fentanyls is often sold as heroin, which in Chicago can come in many forms, like hard grey pebbles or off-white powders. With the naked eye, there is no way to tell if fentanyl is there. But the doses are different, and accidental overdoses happen when people believe they’re doing a dose that they think their body can handle, but instead turns out to be way more than they expected.

So people who have long relied on CRA for sterile syringes and the overdose antidote, naloxone, are now using the drug checking service to learn if the drugs sold to them as heroin actually contain illicit fentanyl, creating a layer of quality control between users and suppliers. Here’s Greg Scott again:

Greg Scott: The entirety of human history involves the use of substances and in the use of substances every human is always using one of their five senses to check it. Does it look right? Does it smell right? Does it taste right? How does it feel? Is it too granular? Is it too chalky?

Zachary Siegel: So, why not add a more objective measure? The drug supply under prohibition is a black box filled with mystery powders. The theory behind drug checking is that if someone knows that the heroin they purchased contains fentanyl, or is only fentanyl, they would measure out much smaller doses and possibly avoid a fatal overdose. So CRA offers a drug checking service, where people can bring residue or trace amounts of illicit drugs for analysis, so they can be better informed about what they’re using. But they’re also mobile, and they load equipment onto their big silver vans that they drive around in neighborhoods on the West and South sides, where the people know who they are and trust them to help.

It sounds simple and reasonable, but there are many hurdles to clear in order to make this a scalable strategy that can work not just in Chicago, but other cities across the country that are seeing illicit fentanyl take over the heroin supply.

Greg Scott: The technology is imperfect, it’s kind of glitchy, it was never designed for this purpose, so we’re having to debug it. We’re having to teach the machines how to be smarter, how to be more sensitive. We’re working with the manufacturers to develop new ways to increase sensitivity, particularly with regard to the detection of fentanyl.

Zachary Siegel: In addition to the struggle to get the machines to behave, funding, legal issues, and stigma present serious barriers to rolling out drug checking nationwide. Historically, harm reduction interventions have run up against notions of agency and the volition of people who use drugs. This is still the case with syringe exchanges and even naloxone distribution. The head of the National Institute on Drug Abuse described addiction as a “disease of free will.”

Can people use drugs and still care for their health? And, in the context of drug checking, does knowing the contents of a drug change consumer behavior? Scott isn’t preoccupied much with theory these days; there’s a public health emergency and his goal is to keep people alive.

Greg Scott: These machines historically have been used by law enforcement to kind of facilitate prosecutorial efforts and to lock people up, or they’ve been used by medical examiners to try to understand what might be in a substance found at a scene, or a crime lab what might have been contributing to an overdose. But that’s about processing dead bodies, and it’s a post-hoc kind of effort. In harm reduction, we serve the living.

Zachary Siegel: Scott briefly stepped in as the interim executive director of CRA under tragic circumstances. In August 2018, the co-founder of CRA, Dan Bigg, died of an accidental overdose at the age of 59. Bigg was an early pioneer in the harm reduction movement, and is best known for promoting the availability of naloxone. Naloxone prevents overdoses from turning fatal by kicking opioids like heroin and fentanyl off of certain receptor sites in the brain.

For decades, naloxone was only used inside of medical settings, by doctors, nurses, paramedics, and anesthesiologists. But early on, Bigg saw the potential for this drug to save lives if put in the hands of people using drugs. His friends and colleagues, they say his ideas [were] revolutionary, and that his work has prevented countless overdose deaths.

Greg Scott: Dan, I mean Dan Bigg, had this idea that we could basically liberate laboratory instruments from labs and from law enforcement agencies and put them on the street and use them for basically the same diagnostic purposes, but for completely different intervention ends. Diagnostically, we’re doing the same thing, we’re looking, in the same way that labs, whether they’re state health labs or law enforcement labs, are looking for compositions, basically chemical compositions of any given substance, we’re doing the same thing and trying to understand what the impact on the consumer is likely to be, and how we can equip consumers with that information directly in sort of a one-to-one interaction, face-to-face interaction and help them make decisions regarding the use of that substance.

Zachary Siegel: Among the drugs in Bigg’s system when he died was acetyl fentanyl, a popular analog on the street that animal studies suggest is five times stronger than heroin. According to the National Institute on Drug Abuse, in 2016, synthetic opioids became the most common drugs involved in overdose deaths.

The DEA has pristine labs and forensic chemists with Ph.D.s to check samples. CRA has Lydia Karch, and watching her I quickly realize how complicated the process is to reconstruct the ingredients list for illicit drugs. She first uses a test strip, which reads positive.

Lydia Karch: And so this one is positive.

Zachary Siegel: So that “heroin” has at least some fentanyl. But Karch’s job is to dig deeper, so she turns to the infrared spectrometer.

Lydia Karch: And so in this particular case, the first match is for mannitol, which isn’t really surprising, that’s a common cut in Chicago.

Zachary Siegel: Mannitol is a sugar alcohol used as filler to dilute heroin, also known as a cut. Lactose is another common one, and this sample has it too. Karch tends to find these cuts in her analysis.

Lydia Karch: And then the next match, which is not surprising, is quinine.

Zachary Siegel: Quinine is another cut.

Lydia Karch: It’s not entirely all that common, but it was used in, oh god what does it go in … malaria medication. And it smells and tastes like heroin. So it used to be a common cut for heroin period, because it would make people think it was heroin. But we’re seeing more is it’s a common cut with fentanyl because you can put fentanyl into a sample and make it look and smell like heroin even though there’s no heroin.

Once I take the quinine out, I don’t really have anything else in here.

Zachary Siegel: So the infrared hasn’t detected anything but cutting agents. No heroin, no fentanyl. But she’s not done. This is the sound of a high-pressure mass spectrometer heating up to check the sample.

[Sound of the machine buzzing]

Lydia Karch: And so it is now giving an alarm for fentanyl. So the high-pressure mass is also agreeing with the test trip that there is fentanyl in this sample.

Zachary Siegel: So that’s two separate technologies giving you the same result. You are pretty confident that there is fentanyl in this sample.

Lydia Karch: Yes.

Zachary Siegel: When Karch finishes up detailing what’s in this sample, she’ll share her results with outreach staff who will then pass the analysis along to the right person. Some participants do real-time checking on the vans, which can take about 10 minutes. Others hand over trace amounts of drugs they’ve been using, and then they get their results the next time they show up to a van site. Since people frequently need new syringes, the same folks usually show up to the same vans throughout the week.

Beyond informing people on a one-to-one basis, Karch’s database of samples is providing a larger snapshot of the illicit drug supply in Chicago.

Lydia Karch: Of the samples I’ve tested that were sold as heroin, about half have fentanyl in them. That’s not a big enough number to really create a map, but I think what we are getting a sense of as well is what a cut profile looks like when fentanyl might be in it. So the presence of quinine, we can’t obviously say that it predicts the presence of fentanyl, but they do tend to go together.

Zachary Siegel: While Karch is busy analyzing the Chicago market, she is also working with other drug-checking organizations, both in the U.S. and internationally, to keep tabs on the wave of illicit fentanyl.

They share information and data libraries, help calibrate the machines, and work together to make drug checking a viable overdose prevention strategy. While this group of drug checkers is primarily looking for fentanyl analogs, they are teaming up with people from other drug-using cultures, like Mitchell Gomez, the executive director of DanceSafe. DanceSafe has a long history of checking drugs used at music festivals, like MDMA, known as ecstasy or molly.

Mitchell Gomez: Starting in the late 1990s, DanceSafe realized that a lot of what was being reported as MDMA incidents at festivals — festivals being kind of a newer term, really, back then it was raves — were not actually being caused by MDMA. There were reports of people basically losing consciousness after taking pills, they were ending up being pulled out on stretchers. A true MDMA-related medical incident usually looks like overheating. A person losing consciousness after taking a pill means there’s something else happening, that’s a different drug. Originally, DanceSafe started a mail-in program. They found a lab that had a pre-existing DEA handling license. They could receive drugs, they could chemically analyze them using GCMS…

Zachary Siegel: That is, gas chromatography mass spectrometry.

Mitchell Gomez: At the time, you had to mail in the sample with a code, and then you would call a phone number, enter the code, and they would tell you what the sample was. And this is really great for people who plan ahead. But for people who just show up at a rave, purchase a pill, and take it, obviously a mail-in system doesn’t work. There’s a few governments in Europe that had started doing these sort of on-site drug checking services. They would set up GCMS at events, at raves. Europe has a slightly more progressive, more rational drug policy so you can get away with things like that in Europe.

But what drug checking is really good at is giving you more information. So it’s not harm elimination, it’s harm reduction.

Zachary Siegel: Europe and Canada have a long history of drug checking. But federal agencies in the U.S., like the Substance Abuse and Mental Health Services Administration (SAMHSA for short) often use the metaphor of a “hijacked brain” to describe how addiction takes over one’s ability to make decisions. In 2017, President Donald Trump appointed Elinore McCance-Katz as the assistant secretary for mental health and substance use within the Department of Health and Human Services. Last year, in October 2018, she weighed in on the drug checking debate in a blog post titled: “For beating the opioid crisis, America has better weapons than fentanyl test strips.”

Referring to test strips that check for fentanyl — that CRA and DanceSafe distribute — McCance-Katz writes that, quote, “The entire approach is based on the premise that a drug user poised to use a drug is making rational choices, is weighing pros and cons, and is thinking completely logically about his or her drug use. Based on my clinical experience,” she goes on to say, “I know this could not be further from the truth.”

McCance-Katz’s opposition carries material consequences for drug checking. SAMHSA distributes over a billion dollars in funds to states as block grants. The policy she put in place prohibits overdose-prevention programs from purchasing fentanyl test strips or other checking technology with SAMHSA grant money. This is the policy despite early research showing the strategy has promise. We’ll get into that research in a bit.

People who use fentanyl test strips to check their drugs come to the opposite conclusion of McCance-Katz. Like activists and organizers Louise Vincent and Jess Tilley, who distribute naloxone, syringes, and test strips on the East Coast, from Massachusetts to North Carolina, and beyond. I caught up with them in Iowa City at a recent harm reduction summit where Vincent and Tilley hosted a session about drug user organizing and activism. Here’s what Vincent told the room about drug checking:

Louise Vincent: It’s like what we would want for anything else. We spend years as drug users becoming good at telling if drugs are good or bad. That’s the mark of a good drug user, right? Like, you can tell what you’re buying. You have to be the guinea pig. The only way to tell what it is, is to use it, and that’s a pretty awful way to find out that something’s poisoned, and that’s a pretty awful way to find out that something’s not right. So drug checking is really important. Like Jess said, if this was any other, if this was a legal substance, we would be out checking the lettuce. So we’re out checking the lettuce.

Zachary Siegel: Vincent is alluding to the way authorities mobilize when, say, romaine lettuce is contaminated with E. coli. While the supply-chain is investigated, people are told to hold off ordering Caesar salad until the contamination is traced back to whichever farm. The romaine is taken off the shelf, but people don’t stop eating greens altogether. They just order the kale Caesar instead.

Vincent and other people using heroin don’t have this luxury. Their bodies are habituated to opioids, and without them, a nasty withdrawal ensues. I asked Jess Tilley if addiction makes drug checking moot, laying out the federal government’s position, that drug use and addiction are irrational, and therefore people who use drugs cannot care for their health.

Jess Tilley: I know that was coming from you so I didn’t throttle you. I knew that wasn’t your thought. I myself, identifying as an injection drug user, I’ve had many people say that, not knowing how I identify, telling me that drug users don’t have the agency to make decisions or to care about their own health. And that is furthest from the truth. Of course there’s always like the exception to the rule, just like there is in any counter-culture, or anybody in society.

Zachary Siegel: Early research about drug checking backs Tilley and Vincent up. A survey study by Johns Hopkins found that 70 percent of people would modify their using behaviors if they knew that their drugs contained fentanyl.

Jon Zibbell: There’s been myths that drug users don’t care about their health, that they have larger issues. Some people even think that if you’re injecting drugs, you’ve already made a horrible decision that everything you do is negative, right, because that thing you’re doing as such is negative.

Zachary Siegel: That’s Jon Zibbell, a researcher studying infectious disease and drug use at RTI International, a nonprofit based in North Carolina. His team published some of the first papers on the ways people use fentanyl test strips.

Jon Zibbell: And what we found, overwhelmingly, 70 percent of people change their injection behavior. So 70 percent of people out of those 125, it’s a small sample, but it was a quick demonstration project, 70 percent out of those 125 did change their behavior in what we call positive ways, and what those markers were, Zach, was that they didn’t use at all. They used a lot less than they originally intended. They did a tester shot like a little bit and they staggered their use with other people. Right? Because if two people are together and they both use and they both overdose there’s no one there to reverse.

Zach, why this is important is because up until now, all of our overdose prevention is ex post facto, after the fact. So we have naloxone for somebody if they do overdose. We don’t have any of what I would call, pre-overdose interventions. Fentanyl test strips provide that because, theoretically, you would use the test strip, test your product, find out there’s fentanyl in it, and then you can adjust your behavior accordingly.

Zachary Siegel: It’s important to note some limitations with the test strips. Because they are super sensitive, they show a positive result even if just trace amounts of fentanyl are present, all it takes is one tiny speck. But at that tiny amount, it’s unlikely there’s enough fentanyl to be psychoactive. There is other potential for false positives and false negatives with all these technologies, which is why having an expert technician like Karch around to use multiple methods is a better option, though it is more expensive.

Though research from Johns Hopkins and experts like Zibbell is important, people who use drugs and others in the harm reduction movement recognize that research alone is not enough to change hearts and minds, let alone policy. Here’s Jess Tilley.

Jess Tilley: Like, we’re at a point in history where we have to check drugs. And I think the only way that we can normalize it and normalize drug-using behavior is doing what we’re doing right now. It’s finally like, enough, we’re sick of our people dying. We’re talking this, we’re talking about it in volume, it’s not one or two crazy conspiracy theorists who are like, “If we just check drugs, everything will be OK!”

Again there’s going to be so much pushback, I don’t expect everybody to say this is the answer and this is such a beautiful thing. But it’s one step towards normalization.

Zachary Siegel: I couldn’t get McCance-Katz on the phone. But through email I asked if her opposition to drug checking has changed, and whether her stance is the same for fentanyl test strips and other technology, like spectrometers at CRA.

A spokesperson for SAMHSA responded, “Yes, her position would apply to those newer/more advanced technologies, as well.” Through email, the spokesperson sent me another quote from McCance-Katz in her own words: “It is not inconceivable to think that people who are severely addicted will actually use the test strips to seek fentanyl — which might be able to give them the high that their current opioid no longer gives them — and which will place them at risk for overdose and death.”

Back in Chicago, I bumped into Sam Tobias, a drug checking analyst in Vancouver, who uses the same technology inside a supervised consumption site, where people use drugs under medical and peer supervision.

Sam Tobias: The main criticism we have in Vancouver with the drug checking project is very different than the criticisms in the United States. In Vancouver, especially, it’s that it’s not enough. No one is saying that we are enabling drug users which is what I’ve heard in the U.S. The main criticism we get from members of the community is that it is not enough because it is not a safe supply.

Zachary Siegel: The concept of a “safe supply” would sidestep the illicit market and its fentanyl problem altogether by giving people pharmaceutical opioids. In Switzerland, for example, people can be prescribed injectable heroin. This approach is spreading, and a new clinic that prescribes injectable heroin recently opened in Glasgow, Scotland.

Sam Tobias: We do not see drug checking as the answer to the safe supply problem. We see it as a step in the right direction because we have to be real in that you’re not going to be able to buy heroin at the pharmacy for several years, if we’re being optimistic. But drug checking is another tool in the tool box of harm reduction strategies that we can use in the meantime, to hopefully give people the information that they want.

Zachary Siegel: Jess Tilley and Louise Vincent want this information. And while research like Zibbell’s is still ongoing, it currently suggests that people do indeed modify their behaviors when they have this information.

It took more than $100,000 to get CRA set up with their machines and to train people to use them. That money came from the CDC, but passed through several different agencies on its way, including the Illinois Department of Public Health and the CDC Foundation. It’s a complicated system. For example, while SAMHSA’s policy prevents their grant money from going to drug checking, other federal agencies have different rules. Specific restrictions can vary on a grant to grant basis. And most harm reduction groups in the U.S. do not have the funding that CRA has, which makes these machines too costly. In the interim, most groups are relying on the test strips.

Another major hurdle is the law. Think about drug checking, logistically, for a moment: People are using drugs, which is against the law, and they’re submitting samples of their drugs to an organization, like CRA, who then tests to see what’s in it, meaning they’re technically in possession of trace amounts of drugs in order to do this work.

Greg Scott: We were operating in an arcane, deeply ambiguous research exemption.

Zachary Siegel: That’s Scott again. Illinois law previously banned most of CRA’s harm-reduction strategies including sterile syringe distribution and possessing drugs for checking. CRA worked hard to pass a law called the Overdose Prevention and Harm Reduction Act that legalizes their work. They also made sure people they served wouldn’t get in trouble for bringing them samples.

Greg Scott: If you are bringing a sample to us for checking you are protected, should be protected, should not be arrested, and we can handle that, and we can put it through the machines, run fentanyl test strips on it, we can do what we need to do, completely lawfully.

Zachary Siegel: The law is on their side here in Illinois, but just next door, in Indiana, it’s still illegal to possess even a syringe without a prescription. Being allowed to possess drugs in order to check them sounds far away in more rural and conservative areas. But the history of harm reduction shows that innovative ideas, like syringe exchanges and naloxone distribution, are often first tried out in cities. And once they’ve been demonstrated to work, then they spread to other areas.

Take Kentucky, where, prior to 2015, there were only underground syringe exchange programs. After a law passed, there are now over 50 programs operating in Kentucky, which proponents emphasize are likely preventing a significant outbreak of infectious disease.

What CRA and their international group of drug checkers does next carries a lot of weight. All eyes are on them to demonstrate that their idea works.

Greg Scott: If you’re doing lifesaving work in harm reduction you have to demonstrate six ways to Sunday all the ways that you’ve met your scopes, and your objectives, and you’ve reduced harm.

Zachary Siegel: It’s going to take time for CRA and their squad of drug checkers to get there. But every day, more than 130 people in the U.S. die from an opioid overdose. Everyone I spoke to for this episode has organized their life’s work around bringing that number down. They don’t view drug checking as a silver bullet to the threat posed by illicit fentanyl, but they do think that, for now, it’s an important tool. Despite top doctors in the government disagreeing with them, they’re forging ahead.

Greg Scott: What’s really of utmost importance to us is working with that individual person who’s now brought in a sample that we have checked and we have determined to be extremely high in fentanyl concentration. So now what do we say with that person? How do we help that person install protective measures in their own use of that drug to prevent their untimely death, and how can we encourage them to go out and spread that information through their network of peers who may have been copping from the same source?

Zachary Siegel: By educating people who think they’re buying heroin to exercise caution, people working in harm reduction and public health organizations hope maybe they can prevent more people from accidentally dying.

Greg Scott: It’s starting to catch on. At first, people, we would tell them what we were doing and they would say, “Wait, what? You can do what?” and it was like science fiction. And then people started to bring samples in and we would check them and we would get results and they would be like, “Huh. That’s interesting. I wondered why it felt that way” … whatever it was. “Why I was unconscious or what I was dopesick two hours later,” or whatever. To finally be in a situation where you know the ingredients is peculiar and I think it’s mind blowing for some people.

Lydia Chain: Zachary, thank you so much for joining us on the show today.

Zachary Siegel: I’m so happy to be here.

Lydia Chain: So this fentanyl crisis isn’t new, but the market seems to keep changing and overdose deaths keep climbing. Can you lay out for us a little bit about what’s going on, why this is unfolding the way it is?

Zachary Siegel: Yeah, this is a very evolving issue. When these fentanyl analogs first started to appear in the heroin market, and it was very concentrated on the East Coast in places like New Hampshire and Massachusetts and Florida. And since then, it’s slowly marching west. And Chicago is a really interesting market because there’s legacy heroin suppliers here because it’s an old city. So, you know, part of what’s happening in Chicago is this old heroin market sort of clashing with the push for synthetic fentanyl analogs which are just easier to traffic and much cheaper to produce. So that’s what’s new, is that the market is volatile and unpredictable which definitely leaves people who are using in peril.

Lydia Chain: So we’ve seen the geographic locations of fentanyl analogs changing. It also seems like they are becoming more potent, more powerful. What’s driving that?

Zachary Siegel:Yeah that’s a really good question and there’s of course, like … This is a black box, right? We don’t know a lot about how this market works because it’s illicit, but people, scholars and researchers, have sort of created concepts to understand this. And one of those is called the Iron Law of Prohibition, which basically posits that the more draconian the enforcement, and the more that interdiction strategies ramp up, that will push suppliers and traffickers to seek more potent, more compact drugs to traffic. And a really good analogy for this is during alcohol prohibition, whereby bootleggers, they didn’t want to smuggle beer and wine. They wanted to smuggle moonshine or bathtub gin. Something that would pack more of a punch and get more people drunk. So there’s less of the powder itself, but it’s far more potent and that can be properly diluted to fill the demand.

Lydia Chain: That’s very interesting. There’s a lot of stories out there about people, especially in law enforcement, coming into accidental contact with fentanyl analogs and experiencing symptoms. What’s the truth there?

Zachary Siegel: It’s been very interesting to see week to week these stories about a police officer responding to an overdose and then reporting vague symptoms or passing out at the scene. And it’s usually, the headlines are usually about police being “exposed” to these fentanyl analogs. And that’s just really not how this drug works. It’s not skin soluble. And so for instance, pharmaceutical companies, it took them millions of dollars and years of research to create what’s called the skin matrix in order to apply fentanyl transdermally. So there’s a transdermal fentanyl patch. And I think because that exists, others might think that fentanyl is a special drug that is skin soluble when these powders really cannot penetrate the skin that way and cause toxicity that way. There’s really no way to touch the drug and come down with any kind of symptoms.

The people who are most at risk of coming into contact with illicit fentanyl and overdosing are people who are using it. People who are injecting it and snorting it, that’s really who is at risk here. It’s important that people responding to overdoses know that they won’t overdose or experience any symptoms if they’re trying to save a life.

Lydia Chain: Zachary Siegel is a freelance journalist in Chicago who covers public health and criminal justice. Our theme music is by the Undark team, and additional music in this episode comes from Kevin Macleod at Incompetech. I’m your host, Lydia Chain. See you next month.